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Case Law Database

Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. ADJ7038469
Regular
Sep 17, 2014

AZIZA SAYED vs. GIORGIO ARMANI, FEDERAL INSURANCE COMPANY

The defendant's petition to appeal an Administrative Director's Independent Bill Review (IBR) determination was dismissed. The Board found the petition premature as it was not first heard by a trial level Workers' Compensation Judge (WCJ). Additionally, the petition failed to comply with numerous procedural requirements, including proper captioning, verification, service, and stating specific grounds for appeal. Consequently, both the petition for reconsideration and the petition appealing the IBR determination were dismissed.

Workers' Compensation Appeals BoardIndependent Bill ReviewPetition for ReconsiderationAdministrative DirectorLabor Code section 4603.6MAXIMUS Federal ServicesInc.Lien claimantOfficial Medical Fee ScheduleWCAB Rules of Practice and Procedure
References
0
Case No. ADJ3580938 (LBO 0389610) ADJ2553702 (LBO 0376341)
Regular
Feb 16, 2016

JOSE YANEZ, vs. SPECTER OFF ROAD, INC.; EMPLOYERS COMPENSATION INSURANCE COMPANY; FARMERS INSURANCE COMPANY

The WCAB granted reconsideration of a decision that limited a hospital's lien claim reimbursement and intended to sanction the hospital for bad faith. This rescission and remand for further proceedings occurred because the trial record was incomplete and failed to comply with WCAB Rule 10566 and *Hamilton*. Specifically, minutes of hearing lacked required information, and it was unclear if the hospital agreed to independent bill review. The WCJ must now address the hospital's arguments regarding bill review and the admissibility of the independent reviewer's report.

WCABPetition for ReconsiderationLien ClaimantMonrovia Memorial HospitalAdministrative Law JudgeJoint Findings of FactNotice of Intention to Impose SanctionsIndependent Bill ReviewerGriff StelznerWCAB Rule 10566
References
1
Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
0
Case No. MISSING
Regular Panel Decision
Dec 27, 2001

MacRo v. Independent Health Ass'n, Inc.

Plaintiffs Cheryl Macro and Kim Zastrow, insured under a group health contract with Independent Health through the Tonawanda City School District, initiated a class action in state court to challenge Independent Health's modification of infertility treatment coverage. Defendant Independent Health removed the case to federal court, asserting ERISA preemption. Plaintiffs moved to remand, arguing that their claims fell under New York Insurance Law, which is exempt from ERISA preemption by the saving clause, and that their health plan qualified as a 'governmental plan' also exempt from ERISA. The District Court granted the plaintiffs' motion, concluding that the claims were indeed saved from ERISA preemption and that the plan was exempt, thus rendering federal subject matter jurisdiction absent. The court accordingly remanded the case back to New York State Supreme Court.

Infertility CoverageHealth Insurance DisputesERISA PreemptionSaving ClauseGovernmental PlansRemoval to Federal CourtSubject Matter JurisdictionNew York Insurance LawClass Action LitigationEmployee Benefits Plan
References
31
Case No. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
1
Case No. ADJ6776885
Regular
Sep 02, 2016

GABRIEL SANTOS vs. PCW CONTRACTING SERVICES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's Petition for Reconsideration and denied both the lien claimant's and defendant's Petitions for Removal. The WCJ's order appointing an independent bill reviewer to assess the value of services was deemed an interlocutory procedural decision, not a final order subject to reconsideration. The WCAB found no substantial prejudice or irreparable injury to warrant removal, and clarified that while facility fees for certain long-term care hospitals are not subject to OMFS or the Administrative Director's IBR process, a WCJ can still appoint an independent bill reviewer.

WCABPetition for ReconsiderationPetition for RemovalLien ClaimantFindings and OrdersIndependent Bill ReviewerFurther Development of RecordReasonable Value of ServicesSubstantial PrejudiceInterlocutory Decision
References
8
Case No. ADJ11329981
Regular
Jan 14, 2019

JEFFERY DANHAUSER vs. HOWROYD WRIGHT EMPLOYMENT AGENCY, INC., ACE AMERICAN INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC., UNITEDHEALTH GROUP, INC., TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA, SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.

This case involved a petition for reconsideration and removal by a lien claimant disputing medical bill payments. The Appeals Board denied reconsideration and dismissed the removal petition, affirming the WCJ's findings. The Board reiterated that disputes over medical bill amounts after review must proceed to Independent Bill Review (IBR), not through the Appeals Board. A decision directing a party to IBR is a threshold determination, making reconsideration the appropriate remedy, not removal.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalAdministrative Law Judge (WCJ)Independent Bill Review (IBR)Substantive RightLiabilityQuasijurisdictionalThresholdLien Claimant
References
2
Case No. ADJ2652747 (VNO 0344824) ADJ3178119 (VNO 0349849) ADJ4566361 (VNO 0401733)
Regular
Nov 12, 2010

MARK RAINE vs. CITY OF BURBANK

This case involves a lien claimant, Advanced Orthopedics, seeking reconsideration of an administrative order appointing an independent bill reviewer. The Workers' Compensation Appeals Board dismissed the reconsideration petition, finding the order was procedural and not a final decision subject to review. The Board also denied the alternative petition for removal, as the claimant failed to demonstrate significant prejudice or irreparable harm. Therefore, the appointment of the bill reviewer stands, and further development of the record will proceed.

WORKERS' COMPENSATION APPEALS BOARDLIEN CLAIMANTPETITION FOR RECONSIDERATIONPETITION FOR REMOVALORDER FOR APPOINTMENT OF INDEPENDENT BILL REVIEWERWCJOFFICIAL MEDICAL FEE SCHEDULEINTERLOCUTORY ORDERPROCEDURAL ORDERFINAL ORDER
References
5
Case No. ADJ10261156
Regular
May 24, 2018

RAUL BOMBARDLY vs. CITY OF FRESNO SANITATION DEPT, RISICO CLAIMS MANAGEMENT FRESNO

The Workers' Compensation Appeals Board granted reconsideration and rescinded the judge's order for defendant to pay $\$4,812.50$ plus interest to a Qualified Medical Evaluator (QME). The Board found that the record lacked admitted evidence to support the order, including the QME's reports and bills. Defendant argued the dispute should be resolved via Independent Bill Review (IBR) as the QME allegedly double-billed for reviewing records. The Board remanded the case for further proceedings to develop the record, acknowledging defendant's argument may have statutory merit.

Panel Qualified Medical EvaluatorPQMEMarcus Vaughn DCRisico Claims ManagementCity of Fresno Sanitation DeptPetition for ReconsiderationOrder Re: Reimbursement of PQME ChargesIndependent Bill ReviewIBRLabor Code section 4622
References
1
Case No. ADJ2498525 (ANA 0409397)
Regular
Oct 05, 2016

JUVENAL RAMIREZ vs. CHAMPION ENTERPRISES, TRAVELERS INSURANCE COMPANY

This case involves a lien claimant, Monrovia Memorial Hospital, appealing a WCJ's order to further develop the record by obtaining an independent bill review opinion on the value of their services. The Appeals Board dismissed the Petition for Reconsideration, finding the order interlocutory and not a final decision. The Board also denied the Petition for Removal, concluding that the lien claimant failed to demonstrate significant prejudice or irreparable harm. The Board affirmed the WCJ's decision to use an impartial bill reviewer, rejecting claims of bias, and noted parties were given an opportunity to address the review's merits.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalLien ClaimantWCJIndependent Bill ReviewerSubstantive RightProcedural OrderInterlocutory DecisionPrejudice
References
5
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